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Rural Remote Health. Author manuscript; available in PMC 2016 January 13. Published in final edited form as: Rural Remote Health. 2015 ; 15(4): 3591.
An exploration of undergraduate medical students' satisfaction with faculty support supervision during community placements in Uganda AG Mubuuke, H Oria, A Dhabangi, S Kiguli, and NK Sewankambo Makerere University College of Health Sciences, Kampala, Uganda
Author Manuscript
Abstract Introduction—To produce health professionals who are oriented towards addressing community priority health needs, the training in medical schools has been transformed to include a component of community-based training. During this period, students spend a part of their training in the communities they are likely to serve upon graduation. They engage and empower local people in the communities to address their health needs during their placements, and at the same time learn from the people. During the community-based component, students are constantly supervised by faculty from the university to ensure that the intended objectives are achieved. The purpose of the present study was to explore student experiences of support supervision from university faculty during their community-based education, research and service (COBERS placements) and to identify ways in which the student learning can be improved through improved faculty supervision.
Author Manuscript
Methods—This was a cross-sectional study involving students at the College of Health Sciences, Makerere University, Uganda, who had a community-based component during their training. Data were collected using both questionnaires and focus group discussions. Quantitative data were analyzed using statistical software and thematic approaches were used for the analysis of qualitative data.
Author Manuscript
Results—Most students reported satisfaction with the COBERS supervision; however, junior students were less satisfied with the supervision than the more senior students with more experience of community-based training. Although many supervisors assisted students before departure to COBERS sites, a significant number of supervisors made little follow-up while students were in the community. Incorporating the use of information technology avenues such as emails and skype sessions was suggested as a potential way of enhancing supervision amidst resource constraints without faculty physically visiting the sites. Conclusions—Although many students were satisfied with COBERS supervision, there are still some challenges, mostly seen with the more junior students. Using information technology could be a solution to some of these challenges. Keywords COBERS; community-based training; students; supervision; Uganda
Mubuuke et al.
Page 2
Author Manuscript
Introduction The global trend in transforming health professions education has promoted communitybased education (CBE) to ensure orientation towards primary health care and community health1-3. During CBE, students learn from the community setting, focusing on population groups and their everyday health problems4. The amount of time students spend in the community and organizational settings may vary. For example, training may take place at a general practice, family planning clinic, community health center or a rural hospital5. During community placements, students learn about social and economic aspects of illness, health services in the community and methods of health promotion, team work, as well as the frequency and types of health challenges encountered in communities outside a teaching hospital setting6.
Author Manuscript Author Manuscript
Community-based education has been recognized as crucial in influencing student career choices as well as addressing community health needs through service learning7. Stanton8 has identified three principles in service learning: 'those who are being served (community) control the service that is provided, those providing a service (eg students) become more competent to serve, and those providing a service also become learners within the community and have significant control over what is learned'. Some studies have acknowledged the importance of CBE and service learning in understanding community needs. For example, Mpofu et al, in a study on student perceptions of community service learning experiences in community health services in South Africa, reported that CBE allows students to empower people within the community to handle their own health needs9. In another study, Mubuuke et al10 reported that CBE not only provides a platform for students to learn, but also allows students to work with people in the community to advocate for better health services. The importance of CBE has seen many medical schools globally increase their communitybased component in the undergraduate student curricula, responding both to the changes in health care and a worldwide consensus that medical education should have more relevance to the health needs of communities11. The focus of CBE is largely on understanding the context within which students are likely to practice and to improve the health needs of the community. It has been reported that, while in the communities, students need guidance and supervision from their medical school faculty to ensure that the intended learning outcomes are achieved2,12-14.
Author Manuscript
In Uganda, where this study was conducted, a key obstacle preventing many people from obtaining primary health care is the fact that the majority of the population (88%) lives in rural communities while most health professionals are employed in urban areas15. It was recently reported that most doctors (70%) and pharmacists (80%) were serving urban populations15. As a way of addressing this, training institutions adopted several measures. For example, Makerere University College of Health Sciences (MaKCHS) introduced CBE into undergraduate curricula16,17. Students at MaKCHS are required to undertake community-based education, research and service (COBERS) modules through placements for a period of 6 weeks each year. During this time, students live within the communities
Rural Remote Health. Author manuscript; available in PMC 2016 January 13.
Mubuuke et al.
Page 3
Author Manuscript
and participate in a number of activities at the health facility, interacting with people in the community and engaging them, to identify and address their priority health needs.
Author Manuscript
At MaKCHS, the COBERS program is aimed at exposing students to public health and primary health care needs of rural communities. The content for COBERS is integrated within the undergraduate medical curricula and is delivered incrementally across the 5 years of study. Key content areas of the COBERS program include community health, community diagnosis and communication, biostatistics, epidemiology, demography, communication skills, community entry protocols, cultural safety, sanitation, health education and promotion, immunization, nutrition assessment, food security, community engagement, health records and information management, HIV/AIDS awareness campaigns (including prevention, treatment and care, palliative care and health systems management at community health facilities). Students undertake community placements beginning in first year and subsequently across all years of study. In the first semester of third year, students propose and implement an intervention project within the community aimed at addressing a priority community health need. In the second semester of fourth year, the students evaluate the impact of their community-implemented project. These COBERS activities are aimed at ensuring that students recognize the importance of developing community partnerships and engaging communities as a means of implementing sustainable healthcare initiatives. Most importantly, from a national public health perspective, there is evidence that such community exposures can encourage students to pursue rural health service18.
Author Manuscript
When students are within the communities, a university-trained supervisor (site tutor) coordinates student activities, facilitates learning and carries out student assessment. Assessment of student learning involves continuous progressive assessment of weekly activities entered in logbooks, tutorial assessment, written examination papers, submitted student reports and oral presentations of students’ activities. At the same time, students are assigned a faculty supervisor from the university whose major role is to guide them through their learning. This supervisory role involves physical visits to address any fears, concerns or challenges the students could be facing. Although this arrangement has been going on at MaKCHS for a long time, it is not known whether the students have been satisfied with the faculty support supervision.
Author Manuscript
Students often encounter apprehension, stress, anxiety, fear, uncertainty, negative emotions and unclear expectations during community placements, all of which can interfere with effective student learning while in the communities19,20. Empirical evidence and a theoretical rationale has been presented on a number of relationships that include associating negative emotion with deficient field preparation, apprehension with poor performance and supervision with low satisfaction19. Literature is replete with evidence suggesting that the quality of student supervision during field placements is related to overall student satisfaction with the placement21-23. To what extent are the students satisfied with the faculty support supervision during their community placements? Review of records at MaKCHS shows that there is little information on students’ views about faculty support supervision during community
Rural Remote Health. Author manuscript; available in PMC 2016 January 13.
Mubuuke et al.
Page 4
Author Manuscript
placements. Therefore, the purpose of this study was to explore students’ views about the supervision received from university faculty during COBERS.
Methods Study setting and design The study was conducted at Makerere University College of Health Sciences, Uganda, between November 2014 and February 2015. The institution trains undergraduate medical students over a 5-year period and the community modules are spread across the 5 years.
Author Manuscript
This was a cross-sectional study in which both self-administered questionnaires and focus groups were used (Appendices I and II). The questionnaires were electronic and were administered in English. A cross-sectional study design was chosen because the study purpose was largely descriptive and data were collected from students across the different years at one point in time24. Study participants The study involved medical students with previous experience of learning in the community. No student was excluded on the basis of year of study. From this criterion, the study thus targeted students in years 2–5. First-year students had not participated in COBERS at the time of the study and thus did not meet the inclusion criterion. Sampling
Author Manuscript Author Manuscript
For the questionnaire survey, simple random sampling was used to select 150 students. For the qualitative part, purposive convenience sampling was used to select students into focus groups. Purposive convenience sampling is a type of sampling in qualitative research where the researcher selects participants at his or her disposal with the required knowledge or experiences to answer the research question25. In this study, the students selected had a previous experience of COBERS and were thus the most suitable to answer the research question. A call for participation into the focus groups was sent out through both email and posting paper notices. Participants were required to express their willingness to participate in the focus groups to one of the researchers who made the selection of students. Students who responded first to the call were recruited. Four focus group discussions, each with six students, were conducted. A minimum number of six participants for a focus group discussion has been previously recommended in literature26. One focus group discussion was conducted for each year of study (ie years 2–5). The focus group discussions were conducted after the questionnaire survey. The number of focus groups to be conducted was not predetermined, but was largely guided by the principle of data saturation where no new themes were emerging, a technique employed in qualitative research27. Although data saturation was actually achieved with the third focus group, the researchers decided to include the fourth focus group such that each year of study was represented. This also added rigor to the study.
Rural Remote Health. Author manuscript; available in PMC 2016 January 13.
Mubuuke et al.
Page 5
Data collection and management
Author Manuscript
Quantitative data were collected using self-administered electronic questionnaires (Appendix I). The measure for satisfaction with supervision was the indication of agreement against each item on the questionnaire. An item where students indicated either ‘disagree’ or ‘neutral’ was not regarded as satisfaction. Response frequencies were tallied. Questionnaire items were developed from a review of literature on student satisfaction surveys with supervision during community based placements/training. To provide a measure of face validity, the questionnaire was first piloted with two students.
Author Manuscript
Qualitative data were collected using focus group discussions that were moderated by one of the researchers. Responses from the focus group discussions were audio-recorded and later transcribed. It was decided to have separate focus groups stratified by year of study due to the fact that the quantitative data revealed key differences in satisfaction across the years. It was envisaged that mixing up the students in a focus group would bias some responses and inhibit key data from emerging, especially for those students who may have felt apprehensive amongst peers. Questions for the focus groups were open-ended and semi-structured (Appendix II), and these were also informed by previous literature. These questions explored participants’ views of what was good with the faculty supervision, challenges and ways forward to improve the supervision. The questions were piloted before use. Data analysis
Author Manuscript
Descriptive and inferential analyses were used for quantitative data28. Analysis focused on identifying significant differences in responses across years 2–5. Chi-squared analysis was used for categorical variables and correcting for continuity, and student t-test was used for continuous data. The Statistical Package for the Social Sciences (SPSS; http:// www.spss.com) was used in analysis, and significance was set at p
Rural Remote Health. Author manuscript; available in PMC 2016 January 13. Published in final edited form as: Rural Remote Health. 2015 ; 15(4): 3591.
An exploration of undergraduate medical students' satisfaction with faculty support supervision during community placements in Uganda AG Mubuuke, H Oria, A Dhabangi, S Kiguli, and NK Sewankambo Makerere University College of Health Sciences, Kampala, Uganda
Author Manuscript
Abstract Introduction—To produce health professionals who are oriented towards addressing community priority health needs, the training in medical schools has been transformed to include a component of community-based training. During this period, students spend a part of their training in the communities they are likely to serve upon graduation. They engage and empower local people in the communities to address their health needs during their placements, and at the same time learn from the people. During the community-based component, students are constantly supervised by faculty from the university to ensure that the intended objectives are achieved. The purpose of the present study was to explore student experiences of support supervision from university faculty during their community-based education, research and service (COBERS placements) and to identify ways in which the student learning can be improved through improved faculty supervision.
Author Manuscript
Methods—This was a cross-sectional study involving students at the College of Health Sciences, Makerere University, Uganda, who had a community-based component during their training. Data were collected using both questionnaires and focus group discussions. Quantitative data were analyzed using statistical software and thematic approaches were used for the analysis of qualitative data.
Author Manuscript
Results—Most students reported satisfaction with the COBERS supervision; however, junior students were less satisfied with the supervision than the more senior students with more experience of community-based training. Although many supervisors assisted students before departure to COBERS sites, a significant number of supervisors made little follow-up while students were in the community. Incorporating the use of information technology avenues such as emails and skype sessions was suggested as a potential way of enhancing supervision amidst resource constraints without faculty physically visiting the sites. Conclusions—Although many students were satisfied with COBERS supervision, there are still some challenges, mostly seen with the more junior students. Using information technology could be a solution to some of these challenges. Keywords COBERS; community-based training; students; supervision; Uganda
Mubuuke et al.
Page 2
Author Manuscript
Introduction The global trend in transforming health professions education has promoted communitybased education (CBE) to ensure orientation towards primary health care and community health1-3. During CBE, students learn from the community setting, focusing on population groups and their everyday health problems4. The amount of time students spend in the community and organizational settings may vary. For example, training may take place at a general practice, family planning clinic, community health center or a rural hospital5. During community placements, students learn about social and economic aspects of illness, health services in the community and methods of health promotion, team work, as well as the frequency and types of health challenges encountered in communities outside a teaching hospital setting6.
Author Manuscript Author Manuscript
Community-based education has been recognized as crucial in influencing student career choices as well as addressing community health needs through service learning7. Stanton8 has identified three principles in service learning: 'those who are being served (community) control the service that is provided, those providing a service (eg students) become more competent to serve, and those providing a service also become learners within the community and have significant control over what is learned'. Some studies have acknowledged the importance of CBE and service learning in understanding community needs. For example, Mpofu et al, in a study on student perceptions of community service learning experiences in community health services in South Africa, reported that CBE allows students to empower people within the community to handle their own health needs9. In another study, Mubuuke et al10 reported that CBE not only provides a platform for students to learn, but also allows students to work with people in the community to advocate for better health services. The importance of CBE has seen many medical schools globally increase their communitybased component in the undergraduate student curricula, responding both to the changes in health care and a worldwide consensus that medical education should have more relevance to the health needs of communities11. The focus of CBE is largely on understanding the context within which students are likely to practice and to improve the health needs of the community. It has been reported that, while in the communities, students need guidance and supervision from their medical school faculty to ensure that the intended learning outcomes are achieved2,12-14.
Author Manuscript
In Uganda, where this study was conducted, a key obstacle preventing many people from obtaining primary health care is the fact that the majority of the population (88%) lives in rural communities while most health professionals are employed in urban areas15. It was recently reported that most doctors (70%) and pharmacists (80%) were serving urban populations15. As a way of addressing this, training institutions adopted several measures. For example, Makerere University College of Health Sciences (MaKCHS) introduced CBE into undergraduate curricula16,17. Students at MaKCHS are required to undertake community-based education, research and service (COBERS) modules through placements for a period of 6 weeks each year. During this time, students live within the communities
Rural Remote Health. Author manuscript; available in PMC 2016 January 13.
Mubuuke et al.
Page 3
Author Manuscript
and participate in a number of activities at the health facility, interacting with people in the community and engaging them, to identify and address their priority health needs.
Author Manuscript
At MaKCHS, the COBERS program is aimed at exposing students to public health and primary health care needs of rural communities. The content for COBERS is integrated within the undergraduate medical curricula and is delivered incrementally across the 5 years of study. Key content areas of the COBERS program include community health, community diagnosis and communication, biostatistics, epidemiology, demography, communication skills, community entry protocols, cultural safety, sanitation, health education and promotion, immunization, nutrition assessment, food security, community engagement, health records and information management, HIV/AIDS awareness campaigns (including prevention, treatment and care, palliative care and health systems management at community health facilities). Students undertake community placements beginning in first year and subsequently across all years of study. In the first semester of third year, students propose and implement an intervention project within the community aimed at addressing a priority community health need. In the second semester of fourth year, the students evaluate the impact of their community-implemented project. These COBERS activities are aimed at ensuring that students recognize the importance of developing community partnerships and engaging communities as a means of implementing sustainable healthcare initiatives. Most importantly, from a national public health perspective, there is evidence that such community exposures can encourage students to pursue rural health service18.
Author Manuscript
When students are within the communities, a university-trained supervisor (site tutor) coordinates student activities, facilitates learning and carries out student assessment. Assessment of student learning involves continuous progressive assessment of weekly activities entered in logbooks, tutorial assessment, written examination papers, submitted student reports and oral presentations of students’ activities. At the same time, students are assigned a faculty supervisor from the university whose major role is to guide them through their learning. This supervisory role involves physical visits to address any fears, concerns or challenges the students could be facing. Although this arrangement has been going on at MaKCHS for a long time, it is not known whether the students have been satisfied with the faculty support supervision.
Author Manuscript
Students often encounter apprehension, stress, anxiety, fear, uncertainty, negative emotions and unclear expectations during community placements, all of which can interfere with effective student learning while in the communities19,20. Empirical evidence and a theoretical rationale has been presented on a number of relationships that include associating negative emotion with deficient field preparation, apprehension with poor performance and supervision with low satisfaction19. Literature is replete with evidence suggesting that the quality of student supervision during field placements is related to overall student satisfaction with the placement21-23. To what extent are the students satisfied with the faculty support supervision during their community placements? Review of records at MaKCHS shows that there is little information on students’ views about faculty support supervision during community
Rural Remote Health. Author manuscript; available in PMC 2016 January 13.
Mubuuke et al.
Page 4
Author Manuscript
placements. Therefore, the purpose of this study was to explore students’ views about the supervision received from university faculty during COBERS.
Methods Study setting and design The study was conducted at Makerere University College of Health Sciences, Uganda, between November 2014 and February 2015. The institution trains undergraduate medical students over a 5-year period and the community modules are spread across the 5 years.
Author Manuscript
This was a cross-sectional study in which both self-administered questionnaires and focus groups were used (Appendices I and II). The questionnaires were electronic and were administered in English. A cross-sectional study design was chosen because the study purpose was largely descriptive and data were collected from students across the different years at one point in time24. Study participants The study involved medical students with previous experience of learning in the community. No student was excluded on the basis of year of study. From this criterion, the study thus targeted students in years 2–5. First-year students had not participated in COBERS at the time of the study and thus did not meet the inclusion criterion. Sampling
Author Manuscript Author Manuscript
For the questionnaire survey, simple random sampling was used to select 150 students. For the qualitative part, purposive convenience sampling was used to select students into focus groups. Purposive convenience sampling is a type of sampling in qualitative research where the researcher selects participants at his or her disposal with the required knowledge or experiences to answer the research question25. In this study, the students selected had a previous experience of COBERS and were thus the most suitable to answer the research question. A call for participation into the focus groups was sent out through both email and posting paper notices. Participants were required to express their willingness to participate in the focus groups to one of the researchers who made the selection of students. Students who responded first to the call were recruited. Four focus group discussions, each with six students, were conducted. A minimum number of six participants for a focus group discussion has been previously recommended in literature26. One focus group discussion was conducted for each year of study (ie years 2–5). The focus group discussions were conducted after the questionnaire survey. The number of focus groups to be conducted was not predetermined, but was largely guided by the principle of data saturation where no new themes were emerging, a technique employed in qualitative research27. Although data saturation was actually achieved with the third focus group, the researchers decided to include the fourth focus group such that each year of study was represented. This also added rigor to the study.
Rural Remote Health. Author manuscript; available in PMC 2016 January 13.
Mubuuke et al.
Page 5
Data collection and management
Author Manuscript
Quantitative data were collected using self-administered electronic questionnaires (Appendix I). The measure for satisfaction with supervision was the indication of agreement against each item on the questionnaire. An item where students indicated either ‘disagree’ or ‘neutral’ was not regarded as satisfaction. Response frequencies were tallied. Questionnaire items were developed from a review of literature on student satisfaction surveys with supervision during community based placements/training. To provide a measure of face validity, the questionnaire was first piloted with two students.
Author Manuscript
Qualitative data were collected using focus group discussions that were moderated by one of the researchers. Responses from the focus group discussions were audio-recorded and later transcribed. It was decided to have separate focus groups stratified by year of study due to the fact that the quantitative data revealed key differences in satisfaction across the years. It was envisaged that mixing up the students in a focus group would bias some responses and inhibit key data from emerging, especially for those students who may have felt apprehensive amongst peers. Questions for the focus groups were open-ended and semi-structured (Appendix II), and these were also informed by previous literature. These questions explored participants’ views of what was good with the faculty supervision, challenges and ways forward to improve the supervision. The questions were piloted before use. Data analysis
Author Manuscript
Descriptive and inferential analyses were used for quantitative data28. Analysis focused on identifying significant differences in responses across years 2–5. Chi-squared analysis was used for categorical variables and correcting for continuity, and student t-test was used for continuous data. The Statistical Package for the Social Sciences (SPSS; http:// www.spss.com) was used in analysis, and significance was set at p
